Roberto Figueroa Caballero sits on a small table at the site of his Maria-ravaged home on the coast of San Juan, Puerto Rico.

Ramon Espinosa/AP

Two weeks after Hurricane Maria slammed into Puerto Rico, President Trump finally took leave of the golf course and visited the devastated U.S. territory. While hundreds of thousands of Puerto Ricans were suffering in darkness, Trump lobbed rolls of paper towels at people and bragged about the disaster relief effort. He cited the official death count, which was just 16 at the time, as evidence that Puerto Rico wasn’t a “real catastrophe” like Hurricane Katrina. “Everybody watching can really be very proud of what’s taken place in Puerto Rico,” the president said.

Later, the death count was revised to 64. Still, anyone who spent 10 minutes in Puerto Rico after the storm knew the official statistic was a lie. You couldn’t get into an Uber in San Juan without hearing about someone whose aunt had been trapped in her home, or a cousin who was still in the hospital. And outside San Juan, especially on the west coast where the hurricane made landfall and in the mountain villages around Utuado, the landscape was littered with abandoned dogs and collapsed houses. Even then, it was impossible to believe that only 64 people had died during what was obviously a very real catastrophe.

Now, thanks to a study published yesterday in the New England Journal of Medicine, we have a better understanding of the human cost of this deadly storm. According to the study, approximately 4,645 “excess deaths” occurred between September 20th, 2017 – the day Maria made landfall on Puerto Rico – and December 31st. That makes Maria the deadliest natural disaster to hit the U.S. in 100 years, with a mortality rate twice as high as Hurricane Katrina in New Orleans in 2005.

The study, which was conducted by researchers at Harvard University, combined both on-the-street reporting and statistical analysis. Researchers visited a random sample of 3,299 houses in Puerto Rico and asked respondents to provide information about household members who had moved or died. From the data, the researchers estimated that, throughout the island, 14.3 deaths had occurred per 1,000 people in a roughly three-month period. Using that number, Harvard estimated that 4,645 excess deaths occurred in Puerto Rico compared to the same period of time the year before.

About one-third of the deaths were attributed to delays or interruptions in health care, which in many cases was a result of widespread power outages across the island for weeks and months after the storm knocked out 80 percent of the island’s grid. And the estimate of 4,645 total deaths, they wrote, “is likely to be conservative since subsequent adjustments for survivor bias and household-size distributions increase this estimate to more than 5,000.”

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This study raises a number of pressing questions, the most obvious being: Why did it take so long for anything like an accurate death count to be tallied? Or, to be more precise: Why did no one in the U.S. federal government – or in Puerto Rican state government – care enough about the people of Puerto Rico to even bother counting the dead?

It’s hard to think of a more profound gesture of disrespect for the people who lost loved ones as a result of the storm. No wonder people are taking to the streets in protest to school closings and other austerity measures by the Puerto Rican government.

During the hurricane and its aftermath, Puerto Rican Governor Ricardo Rosselló has hardly been a profile in courage. Not surprisingly, his officeresponded to the new death toll with a weak statement touting a study they have commissioned with George Washington University: “As the world knows, the magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities. We have always expected the number to be higher than what was previously reported. That is why we commissioned The George Washington University (GWU) to carry out a thorough study on the number of fatalities caused by Hurricane Maria which will be released soon. Both studies will help us better prepare for future natural disasters and prevent lives from being lost.”

But other political leaders in Puerto Rico have been outspoken. San Juan Mayor Carmen Yulin Cruz, who became a hero to many Puerto Ricans for her willingness to criticize President Trump and FEMA’s recovery efforts, immediately raised the provocative idea that the low official death toll wasn’t an oversight, or a sign of incompetence, but a deliberate cover-up.

When a crisis is before you, you have 2 choices: you speak up or you become an accomplice to the cover up. I always choose to speak up.

Given what’s a stake, Mayor Cruz and others will undoubtedly have more to say about this “cover-up” – if that’s the right word – in the upcoming days and weeks.

Was the lack of interest in an accurate death count a product of racism in the Trump administration? Was it an attempt to avoid paying burial expenses and death benefits to Puerto Ricans? There are already calls for a congressional investigation. But if nothing else, this new study underscores the loss and suffering of Puerto Ricans in the aftermath of the storm, as well as the cost of Trump’s arrogance and incompetency. While he was tossing out paper towels, Americans were dying.

And now, as I write this in the mountains of Puerto Rico, where vines grow on abandoned houses and many roads are still impassable, the skies are darkening again and the wind is kicking up. Hurricane season starts June 1st.